Wednesday, January 2, 2013

The Latest Prognostication for Stroke

We have a fairly robust vascular neurology program at my institution, and – unsurprisingly – they're rather pro-thrombolysis. While our disagreements over the efficacy of thrombolysis for acute strokes are generally set aside in a truce stemming from academic and research interests, the main philosophical difference between our services remains this: the difference between eligible and indicated.Vascular neurology tends to treat these terms as synonymous regarding thrombolysis and acute stroke, while it's clear from the literature that not every patient benefits from thrombolysis. The most recent issue of Neurology features another prognostic tool, the SPAN-100, which is the simplest by far: NIHSS + age. If this score is >100, fewer patients will benefit from tPA than will be harmed. There's a quality-of-life discussion to be had regarding individualized treatment decisions in SPAN-positive patients, and this is derived from a very small cohort, but it's consistent with the remaining literature.The accompanying editorial is also pro-thrombolysis, but does recognize these scoring systems are important clinical tools in educating patients and families regarding the potential for benefits and harms. Most importantly, this table from the editorial summarizes the growing body of literature available to assist the decision-making process:

I look forward to seeing these develop such that clinicians have better tools with which to separate eligible from indicated.